Hyperglycemia control of the nil per os patient in the intensive care unit: introduction of a simple subcutaneous insulin algorithm.

backgroundDiabetes patients in the intensive care unit (ICU) and either nil per os, on enteral feedings, or on total parenteral nutrition are often treated with sliding-scale insulin (despite lack of evidence showing benefit) or intravenous insulin (IVI) infusion, a nursing intensive procedure requiring hourly glucose measurements, and insulin rate adjustments. We introduced a subcutaneous insulin algorithm (SQIA) that would equal the glucose goals for IVI but have the simplicity of q4 hour adjustable sliding-scale insulin.

methodsAs part of a quality improvement project, we developed a simple SQIA that titrates insulin to the requirements of the individual patient. Glucoses were monitored q4 h and SQ rapid-acting insulin administered based on both the previous insulin dose and current glucose level. Fourteen consecutive hyperglycemic patients admitted to ICU-A were placed on the SQIA. Glucose and insulin data were also obtained on 18 patients in an identical ICU-B who were treated with the usual IVI protocol, which is q1-2 h.

resultsDuration on the SQIA was 4.5 ± 0.6 days (range 0.8-7) and on IVI 1.9 ± 0.6 days (range 0.25-9). Due to difference in length on protocols, only data for the first 3 days could be statistically compared. During this time, the mean ± standard error of glucoses for the SQ and IV groups were 157.3 ± 3.8 and 157.0 ± 2.2 (not significant). No differences were seen in hypoglycemia rates.

conclusionsA simple SQIA allows insulin doses to be adjusted to the individual patient's needs and meet current ICU goals for glycemic control. Its adoption may reduce the workload of nurses.